An enterocele, also known as small bowel prolapse, is a type of pelvic organ prolapse (POP) that occurs when the structural support of the pelvis weakens. This condition involves the small intestine descending from its normal position and pressing against the wall of the vagina, creating a noticeable bulge or hernia. An enterocele is defined by the involvement of the small intestine and overwhelmingly affects women.
Defining Enterocele and Its Location
An enterocele is a hernia formed when a section of the small intestine pushes into the space between the vagina and the rectum, known as the cul-de-sac of Douglas. This descent occurs due to a failure in the pelvic floor muscles and connective tissues that suspend the organs. The resulting bulge typically appears at the top and back wall of the vagina.
This condition is anatomically distinct from other forms of pelvic organ prolapse. A cystocele involves the bladder pushing into the front wall, while a rectocele features the rectum bulging into the back wall. An enterocele is a posterior vaginal wall defect where the small bowel shifts, often occurring higher up than a rectocele. The integrity of the pelvic floor, a structure of ligaments and muscles, is compromised, allowing the small intestine to drop into this weakened area.
Identifying the Causes and Risk Factors
The primary cause of an enterocele is damage or chronic stress to the pelvic floor support structures. The most significant risk factor is pregnancy and vaginal childbirth, especially multiple deliveries, which can stretch or tear the supporting muscles and fascia. The force exerted during labor can directly weaken the tissues that hold the small bowel in place.
Chronic conditions that increase intra-abdominal pressure also contribute to the development of this prolapse. These include chronic straining from constipation, persistent heavy lifting, or a chronic cough. Furthermore, the loss of estrogen after menopause decreases the strength and elasticity of connective tissues, making postmenopausal women more susceptible.
A prior hysterectomy is another major factor because the uterus provides significant structural support to the top of the vagina. Removing this support increases the rectovaginal space, making it easier for the small intestine to descend into the vacated area. Being overweight or obese adds constant downward pressure on the pelvic floor, accelerating the weakening of supportive ligaments and muscles.
Recognizing the Signs
Symptoms often vary depending on the size of the prolapse, with many women experiencing no noticeable signs in mild cases. When symptoms occur, the most common complaint is a sensation of pelvic fullness, pressure, or a feeling that something is falling out of the vagina. This feeling often worsens by the end of the day or after prolonged standing, as gravity increases pressure on the pelvic floor.
A person may also feel a soft, mobile bulge or mass within the vagina, which represents the small intestine pressing into the vaginal wall. Lower back pain is another frequent symptom, particularly a dull ache that resolves quickly when lying down. The prolapse can also interfere with sexual function, causing discomfort or pain during intercourse (dyspareunia).
While an enterocele primarily involves the small bowel, it can cause secondary functional issues with the rectum. The prolapsed tissue can press on the rectum, leading to difficulty with bowel movements or the sensation of incomplete emptying. To fully evacuate, some women may need to apply manual pressure to the vaginal area, a technique known as splinting, to push the prolapsed tissue out of the way.
Diagnosis and Treatment Options
A physician diagnoses an enterocele through a comprehensive physical examination, including a pelvic exam. During the exam, the doctor will assess the vaginal walls while asking the patient to strain, cough, or bear down. These maneuvers temporarily increase abdominal pressure and make the prolapsed small bowel more apparent, confirming its location and severity.
If the diagnosis is uncertain or if multiple prolapses are suspected, imaging tests may be ordered to confirm the contents of the bulge. Specialized X-ray studies, such as defecography or fluoroscopy, can be performed to visualize the small bowel’s descent during straining. The treatment approach is determined by the severity of symptoms and the impact on quality of life, ranging from non-surgical management to surgical repair.
Non-surgical treatments focus on managing symptoms and preventing the prolapse from worsening. Lifestyle modifications are often recommended, such as weight loss, a high-fiber diet to prevent constipation, and smoking cessation to reduce chronic coughing. A pessary, a removable silicone device inserted into the vagina, is a highly effective non-surgical option that physically supports the prolapsed organs and holds them in their proper position.
For more severe cases, or when non-surgical methods fail, surgical intervention is the definitive treatment to restore the pelvic anatomy. The goal of surgery is to push the small bowel back into the abdominal cavity and reinforce the weakened vaginal support structures. Techniques include colporrhaphy, which repairs the defect through the vagina, and sacrocolpopexy, an abdominal approach using synthetic mesh to permanently suspend the top of the vagina.